History

Specific inquiry should be made into risk factors for the development of diabetic retinopathy. These include the type of diabetes, the duration, and the degree of control. After 20 years of disease, nearly all patients with type 1 and 60% of patients with type 2 diabetes have some degree of retinopathy. The risk increases with the duration of disease. Hence, diabetic retinopathy is more likely to be present in patients older than 40 years.

The Diabetes Control and Complications Trial (DCCT) clearly demonstrated that tighter control of blood sugar is associated with reduced incidence of diabetic retinopathy. Glycosylated hemoglobin [HbA1c] should be less than 7%.

Proteinuria is a good marker for the development of diabetic retinopathy; thus, patients with diabetic nephropathy should be observed more closely. Elevated blood pressure increases the risk for retinopathy; patients with diabetes and hypertension may develop diabetic retinopathy with superimposed hypertensive retinopathy. Elevated triglyceride and lipid levels increase the risk for retinopathy, whereas normalization of lipid levels reduces retinal leakage and deposition of exudates.

Finally, diabetic retinopathy can progress rapidly in pregnant people, especially those with preexisting diabetic retinopathy.

Physical Examination

Funduscopy under stereopsis and high magnification should be performed on every patient with diabetes to assess for diabetic macular edema (DME) and diabetic retinopathy. An indirect ophthalmoscope does not provide adequate magnification for the diagnosis of diabetic macular edema.

Diabetic macular edema is defined as retinal thickening within two disc diameters of the center of the macula. Focal edema is associated with hard exudate rings resulting from leakage from microaneurysms. Diffuse edema results from breakdown of the blood-retinal barrier with leakage from microaneurysms, retinal capillaries, and arterioles.

Clinically significant macular edema (CSME), as defined by the Early Treatment Diabetic Retinopathy Study (ETDRS), exists with any of the following findings:

Retinal thickening within 500 µm of the center of the fovea
Hard, yellow exudates within 500 µm of the center of the fovea with adjacent retinal thickening
At least one disc area of retinal thickening, any part of which is within one disc diameter of the center of the fovea

Visual acuity should also be measured. Although visual acuity does not aid in the diagnosis of CSME—initially, at least, patients may have a visual acuity of 20/20—it is an important parameter in following the progression of CSME.

The status of the posterior hyaloid should also be determined. In CSME, the posterior hyaloid is detached, taut, and thickened.

Differential Diagnoses

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Author

Emmanouil Mavrikakis, MD, PhD Ophthalmologist-in-Chief, Consultant Vitreoretinal Surgeon, Ophthalmology Department, G Gennimatas Athens General Hospital, Greece

Emmanouil Mavrikakis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, European Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Baseer U Khan, MD Associate Professor of Ophthalmology, University of Toronto Faculty of Medicine; Ophthalmologist, Clarity Eye Institute, Canada

Baseer U Khan, MD is a member of the following medical societies: Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Wai-Ching Lam, MD, FRCSC Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine, Canada

Wai-Ching Lam, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Canadian Ophthalmological Society, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Novartis for speaking and teaching; Received honoraria from Allergan for review panel membership; Received honoraria from Alcon for review panel membership; Received honoraria from Bayer for consulting; Received honoraria from Alcon for review panel membership; Received honoraria from Novartis for review panel membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Macular Edema in Diabetes Clinical Presentation

History

Physical Examination

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